CHAPTER 1
It began, innocently enough, with a fall.
Beth Stillwell, a slight, thirty-five-year-old mother of three with kind eyes and an infectious laugh, was shopping at Thrifty Dollar Store with her kids in tow. She'd been stocking up on school supplies and home staples when she lost her balance and tumbled to the grimy linoleum floor. It was bad enough to have to shop at the dollar store, something new since her separation from her philandering husband of fifteen years. It was downright humiliating to be sprawled out on their floor, her leg bent in a painful angle beneath her.
Beth wasn't hurt, but as her six-year-old daughter Emily tried to help her stand, her left leg felt weak, almost rubbery. Leaning against a shelf stocked with cheap soap, Beth took a tentative step only to have the leg nearly buckle beneath her. She kept her balance, and after another awkward step, decided she could walk on it.
The strength in Beth's left leg mostly returned, but a slight stiffness and a disconcerting drag lingered for weeks. Beth's sister told her to see a doctor. Beth said she would, but it was an empty promise. Running a licensed day care out of her Jamaica Plain home, Beth was in charge of seven kids in addition to her own, and any downtime put tremendous strain on her limited finances. She rarely had time to make a phone call. But the leg was definitely a bother, and the lingering weakness was a constant worry. She occasionally stumbled, but the last straw was losing control of her urine while in charge of toddlers who could hold their bladders better than she could. That drove her to the doctor.
An MRI confirmed a parasagittal tumor originating from the meninges with all the telltale characteristics of a typical meningioma: a brain tumor. The tumor was already big enough to compress brain tissue, interrupting the normal complex communication from neuron to neuron and causing a moderate degree of edema, swelling from the pressure on the brain's blood vessels.
Beth would need surgery to have it removed.
* * *
Dr. Carrie Bryant stood in front of the viewbox, examining Beth Stillwell's MRI. A fourth-year neurosurgical resident rotating through Boston Community Hospital (BCH), she would be assisting chief resident Dr. Fred Michelson with Beth's surgery. The tumor pressed upon the top of the brain on the right side. Carrie could see exactly why Beth's left leg had gone into a focal seizure and why she'd lost control of her urine. It was not a particularly large mass, about walnut-sized, but its location was extremely problematic. If it were to grow, Beth would develop progressive spasticity in her leg and eventually lose bladder control completely.
Carrie absently rubbed her sore quadriceps while studying Beth's films. She had set a new personal best at yesterday's sprint distance triathlon, finally breaking the elusive ten-minute-mile pace during the run, and her body was letting her know she had pushed it too hard. Her swim and bike performance were shaky per usual, and all but guaranteed a finish in the bottom quartile for her age group-but at least she was out there, battling, doing her best to get her fitness level back to where it had been.
Carrie's choice to jump right into triathlons was perhaps not the wisest, but she never did anything half measure. She enjoyed pushing her body to new limits. She'd also used the race to raise more than a thousand dollars for BCH: a tiny fraction of what was needed, but every bit helped.
BCH served the poor and uninsured. Carrie felt proud to be a part of that mission, but lack of funding was a constant frustration. In her opinion, the omnipotent budgeting committee relied too heavily on cheap labor to fill the budget gap, which explained why fourth- and fifth-year residents basically ran the show whenever they rotated through BCH. Attending physicians, those docs who had finished residency, were supposed to provide oversight, but they had too much work and too few resources to do the job.
If the constant budget shortfalls had a silver lining, it could be summed up in a single word: experience. With each BCH rotation the hours would be long, the demands exhausting, but Carrie never groaned or complained. She was getting the best opportunity to hone her skills.
Thank goodness Chambers University did its part to fund the storied health-care institution, which had trained some of Boston's most famous doctors, including the feared but revered Dr. Stanley Metcalf, staff neurosurgeon at the iconic White Memorial Hospital. For now, the doors to BCH were open, the lights on, and people like Beth Stillwell could get exceptional medical care even without exceptional insurance.
So far, Beth had been a model patient. She'd spent two days in the hospital, and in that time Carrie had had the pleasure of meeting both her sister and her children. Carrie prepped for Beth's surgery wondering when having a family of her own would fit into her hectic life. At twenty-nine, she had thought it might happen with Ian, her boyfriend of two years, but apparently her dedication to residency did not jibe with his vision of the relationship. She should have known when Ian began referring to his apartment as Carrie's "on-call room" that their union was headed for rocky times.
At half past eleven, Carrie was on her way to scrub when Dr. Michelson stopped her in the hallway.
"Two cases of acute lead poisoning just rolled in," he announced.
Carrie smiled weakly at the dark humor: two gunshot victims needed the OR.
"We can do Miss Stillwell at five o'clock," Michelson said. It was not a request. Working at one of New England's busiest trauma hospitals meant that patients often got bumped for the crisis of the moment, and Dr. Michelson fully expected Carrie to accommodate him.
Carrie would have been fine with his demand regardless. Her social calendar had been a long string of empty boxes ever since Ian called things off. During the relationship vortex, Carrie had evidently neglected her apartment as well as her friends, and it would take time to get everything back to pre-Ian levels. Carrie agreed to move Beth's surgery even though she had no real say in the matter.
The time change gave Carrie an opportunity to finish the rest of her rotations on the neurosurgical floor. She met with several different patients, and concluded her rounds with Leon Dixon, whom Dr. Metcalf had admitted as a private patient that morning. She would be assisting Dr. Metcalf with his surgery the next day.
Carrie entered Leon's hospital room after knocking, and found a handsome black man propped up in his adjustable bed, drinking water through a straw. Leon was watching Antiques Roadshow with his wife, who sat in a chair pushed up against the bed. They were holding hands. Leon was in his early fifties, with a kind but weathered face.
"Hi, Leon, I'm Dr. Carrie Bryant. I'll be assisting with your operation tomorrow. How you feeling today?"
"Pre-eh-eh-eh-eh."
"I'm Phyllis, Leon's wife. He's feeling pretty crappy, is what he's trying to say."
Carrie shook hands with the attractive woman who had gone from being a wife to a caregiver in a matter of weeks. The heavy makeup around Phyllis's tired eyes showed just how difficult those weeks had been. Carrie had yet to review Leon's films, but was not surprised about his speech problems; the chart said he'd presented aphasic. She doubted he'd stuttered before, but she was not going to embarrass him by asking.
"Leon, could you close your eyes and open your mouth for me?" Carrie asked.
Leon got his eyes shut, but his mouth stayed closed as well. Carrie sent a text message to Dr. Nugent in radiology. She wanted to look at his films, stat.
"He has a lot of trouble following instructions," Phyllis said as she brushed tears from her eyes. "Memory and temper problems, too."
Something is going on in Leon's left temporal lobe, Carrie thought. Probably a tumor.
Carrie observed other symptoms as well. The right side of Leon's face drooped slightly, and his right arm drifted down when he held out his arms in front of him with his eyes closed. His reflexes were heightened in the right arm and leg, and when Carrie scraped the sole of his right foot with the reflex hammer, his great toe extended up toward his face-a Babinski sign, indicating damage to the motor system represented on the left side of Leon's brain.
Carrie took hold of Leon's dry and calloused hand and looked him in the eye.
"Leon, we're going to do everything we can to make you feel better. I'm going to go look at your films now, and I'll see you tomorrow for your surgery." Carrie wrote her cell phone number on a piece of paper. Business cards were for after residency. "If you need anything, this is how to reach me," she said.
Carrie preferred not to cut the examination short, but a text from Dr. Robert Nugent said he'd delay his meeting for Carrie if she came now. Carrie was rushed herself. She needed to get to Beth Stillwell for her final pre-op consultation.
Dr. Nugent, a married father of two, was a competitive triathlete who had finished well ahead of Carrie in the last race they had done together. Over the years, Carrie had learned that it paid to be friends with the radiologists for situations just like this, and nothing fostered camaraderie quite like the race circuit.
The radiology department was located in the bowels of BCH, in a windowless section of the Glantz Wing, but somehow Dr. Nugent appeared perpetually tan, even after the brutal New England winter.
"Thanks for making some time for me, Bob," Carrie said. "Leon just materialized on my OR schedule and I haven't gotten any background on him from Dr. Metcalf yet."
Dr. Nugent shrugged. He knew all about Dr. Metcalf's surprise patients. "Yeah, from what I was told, Dixon's doctor is good friends with Metcalf."
"Let me guess: Leon has no health insurance."
"Bingo."
Carrie chuckled and said, "Why am I not surprised?"
It was unusual to see a private patient at Community. Just about every patient was admitted through the emergency department and assigned to resident staff. Dr. Metcalf was known for his philanthropy, and when he rotated through Community he often took on cases he could not handle at White Memorial because of insurance issues.
All the residents looked forward to working with Dr. Metcalf, and Carrie's peers had expressed jealousy more than once. Assisting Dr. Metcalf was the ultimate test of a resident's skill, grace under the most extreme pressure. Dr. Metcalf had earned a reputation for being exacting and demanding, even a bully at times, but his approach paid off. He taught technique, didn't assume total control, and was supremely patient with the less experienced surgeons. Like many world-class surgeons, Dr. Metcalf was sometimes tempestuous and always demanding, but Carrie was willing to take the bitter with the sweet if it helped with her career.
Dr. Nugent put Leon's MRI films up on the viewbox.
"It's most likely a grade three astrocytoma," he said.
The irregular mass was 1.5 by 2 centimeters in size, located deep in the left temporal lobe and associated with frondlike edema. No doubt this was the cause of Leon's aphasic speech and confused behavior.
"So Dr. Metcalf's scheduled to take this one out tomorrow," Dr. Nugent said.
"As much as he can, anyway."
Dr. Nugent agreed.
Carrie was about to ask Dr. Nugent a question when she noticed the time. She was going to be late for the final pre-op consultation with Beth. Damn. There were never enough hours in the day.
Carrie made it to Beth's hospital room at four thirty and found the anesthesiologist already there. By the end of Carrie's consult, Beth looked teary-eyed.
"You'll be holding your children again in no time, trust me," Carrie assured her.
Even with her head newly shaved, Beth was a strikingly beautiful woman, young and vivacious. Despite Carrie's words of comfort, Beth did not look convinced.
"Just make sure I'll be all right, Dr. Bryant," Beth said. "I have to see my kids grow up."
At quarter to five, Beth was taken from the patient holding area to OR 15. Carrie had her mask, gown, and head covering already donned, and was in the scrub room, three minutes into her timed five-minute anatomical scrub, when Dr. Michelson showed up.
"How would you feel about doing the Stillwell case on your own?" he asked. "The attending went home for the day, and I got a guy with a brain hemorrhage who's going to be ART if I don't evacuate the clot and decompress the skull."
Carrie rolled her eyes at Michelson. She was not a big fan of some of the medical slang that was tossed around, and ART, an especially callous term, was an acronym for "approaching room temperature," a.k.a. dead.
"No problem on Stillwell," Carrie said. Her heart jumped a little. She had never done an operation without the oversight of an attending or chief resident before.
Quick as the feeling came, Carrie's nerves settled. She was an excellent surgeon with confidence in her abilities, and, if the hospital grapevine were to be believed, the staff's next chief resident. It would certainly be a nice feather in her surgical cap, and helpful in securing a fellowship at the Cleveland Clinic after residency.
"Unfortunately, I'm going to need OR fifteen. Everything else is already booked," Michelson said.
Carrie nodded. Par for the course at BCH. "Beth can wait," she said.
"I checked the schedule for you. OR six or nine should be open in a couple of hours."
Carrie did some quick calculations to make sure she could handle the Stillwell operation and still be rested enough to assist Dr. Metcalf with Leon's operation in the morning. Three to four hours, tops, Carrie thought, and Beth will be back in recovery.
"No problem," Carrie said. "I'll let you scrub down and save the day."
"Thanks, Doc Bryant," Michelson said. "But you're the real lifesaver here. I don't think there's another fourth year I'd trust with this operation."
"Your faith in me inspires."
Carrie did not mention the promise she'd made to Beth during her pre-op consultation. Michelson would not have approved. If one thing was certain about surgery, it was that nothing, no matter how routine or simple it seemed, was ever 100 percent guaranteed.
Copyright © 2015 by Michael Palmer
